VOL: 98, ISSUE: 46, PAGE NO: 50
Dinah Gould, PHD, BSc, RGN is professor of nursing, South Bank University, London
Using hand decontaminants correctly is a skilled activity that all health professionals need to learn and practise. All health professionals need to acquire an appropriate technique at the beginning of their careers, with continuing professional development to update them and inform them of new advances in research and technology.
Decontamination using a traditional aqueous solution
For decontamination using a traditional aqueous solution, a sink with elbow- or foot-operated taps should be used, if possible. This is important in order to avoid direct touching and subsequently transferring micro-organisms either to the clean hands or the hands of the next person.
The hands should be moistened before adding the product, then vigorously rubbed together. Contact of the solution with all surfaces: the palms, dorsum, the tips of the fingers, the interdigital spaces, wrists and thumbs should be achieved.
Thorough rinsing is necessary to remove all traces of the product to reduce the risk of developing skin irritation or allergy through prolonged contact. In the past it was sometimes recommended that the hands should be held with the fingers pointing downwards after washing to prevent water flowing over the wrists and contaminating them. There is no evidence to support this.
Decontamination using alcohol solutions
When using alcoholic solutions, 3-5ml should be applied to the cupped hands, then massaged thoroughly until all surfaces receive contact. It is important to remember that alcohol dries very quickly. When it is used to decontaminate hands, particular care must be taken to ensure that every surface receives contact before evaporation can take place. The introduction of alcohol handrubs and gels containing emollients reduce the rate at which the solution can evaporate, thus prolonging the time available to ensure coverage of all the hand surfaces.
The effect of incorporating emollients into antiseptic solutions is receiving attention: they must not reduce bactericidal activity. Attention is being also paid to the cosmetic acceptability of products, as it has become apparent that, unless staff like what is available, they will not use it.
Duration of hand decontamination
If all surfaces of both hands are to are to have adequate contact with the chosen product, the duration of decontamination must be sufficient to allow for this. Fifteen seconds has been suggested as ideal (Larson, 1995).
Damp surfaces transfer micro-organisms more effectively than dry ones. Friction from the paper towel is important in helping to remove micro-organisms. It is probably of the greatest significance in removing bacteria after a quick, perfunctory decontamination. Drying is also an important aspect of staff welfare by helping to prevent sore, chapped skin. Soft, absorbent paper towels are more acceptable than hard ones.
Presentation and packaging
Presentation and packaging may seem trivial aspects but they are increasingly recognised as important, not least by the pharmaceutical companies responsible for manufacture and marketing.
Bars of soap should never be used when undertaking any form of patient care in any clinical setting. Gram-negative bacteria can multiply on the damp surface of hard soap, and the cracks that appear when the soap is old and dry can still be moist within, harbouring bacteria which can contribute to cross-infection.
Pump-operated canisters of handrub placed at the bedside encourage compliance because they obviate the need to walk to a sink, especially during busy periods. Aqueous soap solutions and chlorhexidine should be dispensed in closed packs which can be used to recharge wall-mounted dispensers.
‘Topping up’ of dispensers should be discouraged because it increases opportunities for contamination. Single-use sachets of hand gels offer significant advantages for staff visiting patients at home, where access to sinks and clean towels can be problematic (Gould et al, 2000).
Gloves are worn to protect staff during universal precautions and to protect patients from the risks of cross-infection. They provide added protection in situations where heavy contamination is likely. In these situations decontamination alone is unlikely to remove microorganisms effectively. Sterile gloves are used in theatre and during invasive procedures in other clinical settings when the body’s defences against infective organisms will be breached (for example, urinary catheterisation). They are expensive, and for most other tasks nonsterile gloves are suitable. Most manufacturers use either latex or polyvinyl chloride (PVC).
The surface of any type of glove can become heavily contaminated. They should be changed between patients and when the health professional performs a ‘clean’ task (such as giving an injection) after a task likely to result in hand contamination (such as performing a bed bath). Wearing gloves for a continuous period of patient care should be strongly discouraged because the increased sweating which gloves induce leach out bacteria from the deeper layers of the stratum corneum and the subungal space (the space beneath the nail), increasing the numbers available to contribute to cross-infection.
There is no real evidence that decontaminating gloves by washing or cleaning with alcoholic handrub is an effective means of decontamination. These practises should not be encouraged.
Hand decontamination and using gloves
Hand decontamination is necessary when gloves are worn. Puncture and leakage is quite common, and even if the gloves remain intact hands can become contaminated when they are removed. Careful decontamination helps to prevent allergic dermatitis. A range of products should be available so that staff who have developed allergies - including latex - can continue to practise safely.
The hands should be kept in the best possible condition through a careful regime of skin care. Bacterial counts rise when skin is damaged, increasing the risk of cross-infection, and having sore hands is a disincentive to correct hand hygiene.
Hands should be protected by applying soaps and aqueous antiseptic solutions to skin that has already been moistened: contact with the product should not be prolonged because it could promote the development of sore, dry skin. Rinsing should be thorough. Hands may be further protected by applying good quality hand cream at the end of the shift and before retiring, with special attention to areas that look dry or inflamed.
All breaks in the skin on hands must be occluded with waterproof dressings, because abrasions provide a portal of entry to parenterally spread viruses such as HIV, hepatitis B and C. Many people who become carriers are unable to recall injury, and it is thought that seroconversion can occur following exposure to minute quantities of blood via tiny, preexisting lesions. Advice should be sought from the occupational health department if a lesion becomes septic, in case antibiotics are necessary.
Care of the nails
Nails should be kept short and clean. Bacteria are present in large numbers in the subungal space. Nail polish is best avoided, as chips and cracks provide niches for bacteria to multiply. They could then be transferred to any object or person that is handled. Similarly the ridges which result as false nails grow out can harbour large numbers of bacteria, and the presence of moisture may result in the development of a reservoir of bacteria.
Rings and wrist watches
The moist environment created beneath a ring or watch increases the number of Gram-negative bacteria on the surface of the skin while at the same time interfering with vigorous and thorough decontamination. Jewellery should be removed during the delivery of patient care. Rings with stones or ridges provide many niches to harbour bacteria.
The need to optimise hand decontamination has been recognised by the Hospital Infection Society and the Infection Control Nurses’ Association (ICNA). Several of their members and other interested professionals have formed a Hand Hygiene Liaison Group (Teare et al, 1999). Its mission is to modify the behaviour of health professionals to produce sustained improvement in agreed hand decontamination standards to improve quality of patient care.
The Hand Hygiene Liaison Group strongly endorses the ICNA guidelines and has been involved in a number of activities since its inception in 1997. These have included active promotion of the need for hand hygiene standards among trust chief executives, advising the Department of Health on matters relating to hand hygiene and identifying important areas for further research and development.